Cheerleading isn’t as aggressive as high-impact sports like football or hockey, but that doesn’t mean it isn’t dangerous.

According to a report published in the journal Pediatrics by the American Academy of Pediatrics (AAP), as cheerleading has become increasingly competitive, more and more cheerleaders are appearing in doctors’ offices with serious injuries.

In the past 30 years, the AAP says, cheerleading has moved from the sidelines of games to center stage as a competitive sport that features stunts and tumbling. And that means more students are participating: from 1990 to 2003, the number of U.S. cheerleaders ages 6 and older rose from 3 million to 3.6 million. Not surprisingly, this popularity is leading to a rise in the number and severity of injuries, prompting the AAP to call for stronger safety guidelines.

“Cheerleading has become extremely competitive in the past few years, incorporating more complex skills than ever before,” report co-author and pediatric-sports-medicine specialist Dr. Cynthia LaBella wrote in a statement. “Relatively speaking, the injury rate is low compared to other sports, but despite the overall lower rate, the number of catastrophic injuries continues to climb. That is an area of concern and needs attention for improving safety.”

At issue is the fact that not all schools and states recognize cheerleading as a sport; sports are subject to safety regulations and training requirements to ensure that participants aren’t exposed to unnecessary risks. If cheerleading were to be recognized as a sport like gymnastics, programs could gain better access to qualified coaches, well-maintained practice facilities and certified trainers and team physicians. Currently only 29 U.S. high school athletic programs classify cheerleading as a sport, and the National Collegiate Athletic Association (NCAA) does not include competitive cheerleading on its list of sponsored sports, which the AAP says must change.

What concerns the AAP is this: cheerleading has accounted for approximately 66% of all catastrophic injuries among female high school athletes over the past 25 years. Direct catastrophic injuries are classified as closed-head injuries, skull fractures and cervical spine injuries that cause permanent brain injury, paralysis and even death.

Even on the less serious side, cheerleaders are most likely to suffer from sprains or strains, which account for 53% of cheerleading-related injuries. The authors say that since 2007, there have been 26,000 cheerleading injuries reported each year. Although spotters are commonly used to keep a close watch during routines, “active spotting of a maneuver does not significantly decrease the number of serious injuries sustained,” according to the AAP, primarily because spotters may not be properly trained.

The report provides some specific suggestions for improving the safety of cheerleading, hoping to reduce injuries. The pediatricians are urging cheerleaders to scale down their signature moves to reduce the risk of falls and catastrophic injuries, recommending, for instance, that pyramid stunts be limited to a height of no more than two people.

In addition, the AAP offers the following tips:

Cheerleading should be designated as a sport in all states, allowing for benefits such as qualified coaches, better access to medical care and injury surveillance.

All cheerleaders should have a preseason physical as well as access to qualified strength and conditioning coaches.

Cheerleaders should be trained in all spotting techniques and attempt stunts only after demonstrating appropriate skill progression.

Pyramid and partner stunts should be performed only on a spring or foam floor, grass or turf. Stunts should never be performed on hard, wet or uneven surfaces. Pyramids should not be more than two people high.

Coaches, parents and athletes should have access to a written emergency plan.

Any cheerleader suspected of having a head injury should be removed from practice or competition and not allowed to return until he or she has clearance from a health professional.